Provider Demographics
NPI:1760830673
Name:PLYMALE, MONICA
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:PLYMALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-1277
Mailing Address - Country:US
Mailing Address - Phone:815-921-9200
Mailing Address - Fax:815-877-8304
Practice Address - Street 1:4401 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1277
Practice Address - Country:US
Practice Address - Phone:815-921-9200
Practice Address - Fax:815-877-8304
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL044010510376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL366006681Medicaid